Going to the ER with Chest Pain

[Arlyss]

After reading Lorraine's post in "Small Talk", I decided to open a thread here. It is very important that we know what many medical professionals do not appear to be aware of: the reasons for chest pain that should be investigated in the ER.

There are three killers, not just one, associated with chest pain that send people to the ER. Investigation should be done regarding all of them:

Problems with the blood flow to the heart muscle. This is the classic heart disease, causing heart attacks. The coronary arteries may have reduced blood flow due to blockage, a heart attack may have occured, or in some people the arteries of the heart may be in spasm. All of these result in pain as the heart muscle is deprived of enough oxygen-rich blood.

Pulmonary embolism - blood clot in the lung

Aortic aneurysm or dissection

The aorta is often over looked. Problems with the aorta continue to kill people - no one knows how many, because not very many autopsies are done.

People with valve problems that result from abnormal tissue often have abnormal tissue in their aorta also. And yet medical professionals look for disease in the arteries of the heart, and then stop there, when the coronary arteries are ok and there is no evidence of a heart attack. They need to look further - at the aorta.

Most medical centers, even small ones, have a CT scanner. A CT with contrast will show the aorta. There is no need to guess, and it should be part of the work up for chest pain in the emergency room. It should also be done if someone visits their doctor - not just tests for the arteries of the heart should be ordered. A test to look at the aorta should also be done. The 64 slice CT is state of the art now, but any CT with contrast will show the aorta.

High blood pressure, or blood pressure that soars rapidly and then falls, should also be a warning. It is hard on the aorta.

Blood pressure often comes down temporarily in the ER when nitro is given. Aortic pain often goes away, at least temporarily, then. It gives a false sense that everything is ok in the chest.

Here is an article from Time that mentions some of this

http://www.time.com/time/magazine/article/0,9171,1098960-4,00.html

And here is the story of a man who waited in the ER, being told it was anxiety, until he died from a torn, bleeding aorta.

http://www.heraldnet.com/stories/06/08/06/100loc_a1healing001.cfm

The technology is there today to "see" the aorta in the chest. We just need to make sure that the aorta is looked at.

Don't let anyone focus on only heart attacks or only valve issues in your chest. Make sure they look at your aorta too - in time to save your life.

Best wishes,
Arlyss

 

[Jkm7]

If I may add something that I think is important for women to know.

Not all women experience heart attack in the same way as men.

When I had my heart attacks, I experienced no pain at all. My symptoms, I have come to learn, were typical for many woman, but not all and not necessarily for men. I had very, very slight nausea, intense flushing (prespired heavily every inch of my body) and extreme unexplained fatigue. Easy to brush off as not heart related, which I did. I considered could this be a heart attack and dismissed it as No Way. I had one, another about 5 days later and a third more intense which finally brought me to the ER. I had seen my father have heart attacks many years ago and my symptoms did not remotely look like his.

I had no pain, no pressure on my chest, no difficulty breathing.....nothing we typically think a heart attack will look like.

 

[kbheart]

I went to the ER in July with chest pain. They did a CT scan and found an aortic aneurysm but missed the dissection. They even did a TEE while I was there and didn't see the dissection. Luckily, the tear wasn't very big. I walked around for 2 more weeks with chest pain before going to the ER again. When they saw how quickly the aneurysm had grown, they operated. It wasn't until I was in surgery that they saw the 2 dissections. Before the surgery, I had 3 CT scans, 1 TEE, and 1 TTE and no one could see either dissection. They could only see the aneurysm and that my valve was giving out. This is rare because the dissections usually show up, but it's a reminder that the tests aren't foolproof and sometimes you have to insist that the chest pain has not gone away. Doctors like to insist that it's just indigestion and I wanted to beleive them.

 

[Arlyss]

Yes, there is a lot of variation when it comes to heart attacks - and finally women are getting some much needed attention in this area. There is a protocol that has been established in the ER for chest pain when the heart is in distress - this is called Acute Cardiac Syndrome. It is well established that they should look for elevated Troponin (cardiac enzyme) in the blood, and EKG abnormalities. When they find this, it is more straight forward.

I have a family member who has coronary artery spasms. Temporarily her arteries were tightening up, and the heart muscle wasn't getting enough blood. She was repeatedly checked locally for heart attack. It did not last long enough to injure her heart muscle, thankfully, so there was no evidence, and of course she was told it was anxiety. Ridiculous! But it meant she had to travel to a major center in order to get a correct diagnosis.

With the aorta, both blood tests and EKG will be normal - EXCEPT if an aortic dissection has somehow affected a coronary artery and blocked blood flow to some part of the heart muscle. So aortic problems/pain are not detected by the established tests for heart attack. You can have aortic dissection and also have a heart attack.

Jkm7, I am so sorry you have problems with coronary arteries, and glad you did go to the ER. I hope you now have the very best care for your heart.

kbheart, what you describe is another terrible problem - failure to find the dissection or to properly respect the aortic pain you were experiencing.
Finding the aneurysm in the presence of chest pain should have been enough.

Even if a tear was not seen, chest pain in the presence of an aneurysm is screaming that something could go very wrong at any time - the aortic wall is under stress - how long will it hold together? Yes, your aneurysm had grown, and it is beyond me why the aorta did not rupture. You are a miracle, and I hope that you will always have your aorta checked periodically for the rest of your life.

Best wishes,
Arlyss

 

[Bradley White]

http://www.nytimes.com/2007/04/08/health/08heart.html

Very recent article about heart attacks in a recent issue of the NY Times entitled "Lessons of Heart Disease, Learned and Ignored." I thought it appropriate and interesting reading for this thread.

Brad

 

[hensylee]

I went to the hospital w/a heart attack and they missed it. they treated me for GERD - which gives some of the same symptoms.

Prior to the episode that sent me to the er, I had teeth pain, ear pain, throat pain. When the event happened, I took a nitro, another, another, then called my dr's office. They said go to the hospital. I was having tightness and pain in my chest and back shoulder area. I called my sister to take me! DUH Lucky for me I already had an appointment scheduled with a cardio who confirmed that I had a heart attack and blocked arteries preventing blood flow to the heart muscle. After the heart attack and prior to the cardio visit, my arms were soooo tired - down to the elbow and I felt no strength at all. Just weakness and tiredness. Guess I was lucky after all, tho.

 

[savysmommy]

My grandmother suffered multiple heart attacks last year before the went diagnosed. This wasn't because of error at the hospital, but because she didn't go because her symptoms were not that of typical heart attack. She experienced nausea and fatigue for 2 weeks, cold sweats and eventually she fainted. After the fainting episode one of her children decided to call an aid car because she was so pale. The determined at the hospital she had several major heart attacks.

I dont know if this has been brought up or not, but I wonder how much of the pain associated with heart attacks has to do with the age at the time of the event. My grandmother is 82 years old, and its widely known that older patients dont feel pain like younger patients. I dont know if its a nerve response or what. When I had my AVR nurses and docs both mentioned that I might have more pain then some older patients because younger people feel it more. So, I wonder if there is any relationship with the pain association and the age of the person experiencing the heart attack, similar to what the doctors explained to me when I had AVR.

 

[briansmom]

The first set of docs completely missed my son's dissection (2 months of complaining about chest pain, fatigue and raised troponin). It sure would have saved my son a lot of pain and agony if they had paid attention.

 

[Chris Ramcharan]

To Arlyss:
I have corresponded with you previously but lost contact. I had CABG triple bypass with AVR (St.Jude 23mm) and ascending aortic repair all done simultaneously in 2000. In 2005 I had a second CABG due to a dissected LIMA bypass during earlier stent implant. I still experience some nausea and chest discomfort and had a CT scan done last month. The results indicated patent bypasses with some mild ischemia but what is disturbing is that they reported a mild fusiform 4cm aortic aneurysm in the same area that was supposedly repaired in 2000 with a dacron patch?? My cardio insists that it is nothing to worry about! I suspect that it is the Dacron patch that is being seen and an artifact since I had the scan done in a different hospital to my initial surgery. Since you are very familiar and knowledgeable about aortic aneurysms I would be grateful for your comments and thoughts. Can there be a 'mild 4cm aneurysm' or does the fusiform nature makes it mild? I have requested a followup echocardiogram to investigate further but again the cardio thinks its not needed? Again thanks for any input. Chris.

 

[Jkm7]

I dont know if this has been brought up or not, but I wonder how much of the pain associated with heart attacks has to do with the age at the time of the event. My grandmother is 82 years old, and its widely known that older patients dont feel pain like younger patients. I dont know if its a nerve response or what. When I had my AVR nurses and docs both mentioned that I might have more pain then some older patients because younger people feel it more. So, I wonder if there is any relationship with the pain association and the age of the person experiencing the heart attack, similar to what the doctors explained to me when I had AVR.

I was in my fifties when I had my heart attacks. Felt no pain at all. But I certainly felt pain from the ByPass surgery which followed.

I was very fortunate that when I arrived in the ER, one of the best cardiologists in our area 'happened' to be in the ER and he took care of me immediately upon my arrival.

 

[kbheart]

Can there be a 'mild 4cm aneurysm' or does the fusiform nature makes it mild? I have requested a followup echocardiogram to investigate further but again the cardio thinks its not needed?

Chris,
When I was first diagnosed with an aneurysm they said it was 4.2 cm. The cardiologist said that it was more of a mild dialation at the aortic root. He said that it could stay at that size for years and never need repaired. He said they usually grow very slowly and they would check it again in a year.

As I mentioned above, that would have been fine and dandy if I weren't having chest pain. They missed the dissections. If you currently have chest pain, I would insist on a follow-up test. My aneurysm went from 4.2 to 5.2 in 2 weeks because of the dissections.

I was under the impression, like you, that once they grafted the aorta, it was fixed and that part couldn't dilate again. Has anyone else heard of a grafted aorta forming a new aneurysm??

Good luck!! Keep pestering those doctors--your health is worth it!

 

[Arlyss]

Hi Chris,

So nice to be in touch with you again. I'm so sorry that you needed a second CABG.

Regarding your aorta, it depends on how the original aortic surgery was done. If part of your ascending aorta was left in place, it is possible for that tissue to later develop an aneurysm.

It is also possible to develop a pseudo aneurysm at the stitching line, where the graft attaches to the aorta.

It will take an expert eye to look at the CT and interpret what is inside your test. A TEE will show detail also, but a "regular" echo typically won't show enough of the aorta. Actually the CT you have had should show everything re. your aorta if it was done with intravenous contrast.

Generally, cardiologists are not trained in aortic disease, so an assessment from an aortic surgeon is needed. It doesn't mean you need surgery, but you do need someone to look at it with expert eyes. Then you will also be assured that it has been properly measured.

Regarding "mild", those kind of words should not be applied to the aorta. The exact measurement should be given, and what that measurement means should be determined in light of each individual.

Best wishes,
Arlyss

 

[Arlyss]

I might add that it is not a good thing to develop further problems with the same part of the aorta after the first aortic surgery. It can be very high risk. Ascending aortic aneurysms that form on tissue left behind involve tissue that was clamped during surgery - some surgeons have raised the concern that this clamping injures already delicate tissue, making it more likely to bulge and tear.

Pseudo aneurysms are very dangerous, because not all of the layers of the wall of the aorta are still there - so one can be holding together only by very fragile tissue.

This is why the aorta should be checked periodically after surgery - so that the person and their surgeon both know whether the suture lines are ok and what is happening with the remaining aorta.

I hope this helps.

Best wishes,
Arlyss

 

[Chris Ramcharan]

Fusiform aortic aneurysm

Fusiform aortic aneurysm

To Kris:
Thanks for the info. I had my original valve surgery in PRico but have since relocated to Tampa Fl and lost contact with my original surgeon. I did have my 2nd CABG at CCF but not familiar with any of the better valve surgeons. Could you recommend one so that I can get at least a second opinion or may be set up an appt. to check out my aneurysm

To Arlyss:
Although I have lost contact I have always followed your BB posts particularly about your husband's condition. I hope he is in good condition even after 3 surgeries. You mentioned that he replaced his mech valve because of vascular strand formation. I wanted to ask you more about this but lost your email address. Was he on Coumadin and still got this condition? I myself am concerned since I seem to be building up alot of Calcium in my vessels esp in the Aorta since on Coumadin? During my last CABG they did a TEE and reported annular mitral calcium buildup. Of immediate concern however, is the latest CT scan report of another aortic aneurysm and the almost utter disconcern of the cardios here in Tampa except that I see my last aortic surgeon whom I have unfortunately lost contact with. Are there any specific symptoms/signs I should be looking out for? If you don't mind I would like very much to renew and keep in contact by email which still is: [email protected]. Thanks for your comments and assistance
Chris R

 

[Arlyss]

I am going to say something very directly here. People have died because physicians did not understand aortic disease. Others may survive, but be very injured.

Don't be one of them. If you have a known aortic aneurysm, look for someone who will take you seriously and also has the knowledge and skill to help you.

This thread is about going to the ER with chest pain. But for those with aortic disease, the goal is not to end up in the ER at all. The risks are much too great.

Chris, I have emailed you.


Arlyss

 

[kbheart]

To Kris:
Thanks for the info. I had my original valve surgery in PRico but have since relocated to Tampa Fl and lost contact with my original surgeon. I did have my 2nd CABG at CCF but not familiar with any of the better valve surgeons. Could you recommend one so that I can get at least a second opinion or may be set up an appt. to check out my aneurysm

Chris,
Sorry I didn't respond sooner, I didn't follow-up with this thread. Gillinov was my surgeon at the Cleveland Clinic and Grimm was my cardiologist. I had emergency surgery so I didn't do any research on who would be best--I took whoever was willing to come in on a Sunday evening. But I think Gillinov did a great job. Grimm specializes in echos so he might be very helpful. Although, I didn't always feel like he was answering my questions. I think if you start a new thread and label it Cleveland Clinic doctors, you'll get a lot of replies.
Good luck!!

 

[Jkm7]

Jkm7, I am so sorry you have problems with coronary arteries, and glad you did go to the ER. I hope you now have the very best care for your heart.


Best wishes,
Arlyss

Thank you, Arlyss. Unfortunately, I am in the waiting room with Mitral Valve problems.

 

[Ross]

I went to the ER in July with chest pain. They did a CT scan and found an aortic aneurysm but missed the dissection. They even did a TEE while I was there and didn't see the dissection. Luckily, the tear wasn't very big. I walked around for 2 more weeks with chest pain before going to the ER again. When they saw how quickly the aneurysm had grown, they operated. It wasn't until I was in surgery that they saw the 2 dissections. Before the surgery, I had 3 CT scans, 1 TEE, and 1 TTE and no one could see either dissection. They could only see the aneurysm and that my valve was giving out. This is rare because the dissections usually show up, but it's a reminder that the tests aren't foolproof and sometimes you have to insist that the chest pain has not gone away. Doctors like to insist that it's just indigestion and I wanted to beleive them.

They completely missed mine even after a catheterizition. It wasn't until my Cardiologist showed up and ordered a catscan, that it was discovered.

 

[Arlyss]

In an emergency, generally a CT scan with contrast or a TEE will find the problem quickly. If it's not an emergency, an MRI/MRA can be done. It's true that tests, as well as the ones who interpret them, are not perfect - but these tests have the best look at the aorta today.

Unfortunately they might do a cath on someone with an aortic problem because they are looking for heart disease. The new 64 slice CT should be great because it can see the coronaries as well as the aorta. When it's not heart disease, this test should avoid unnecssarily putting a catheter up into a fragile, possibly already torn aorta. Many centers are getting 64 slice CT now.

Best wishes,
Arlyss

 

[Arlyss]

Medical Paper from U of Minnesota

Medical Paper from U of Minnesota

I am going to revive this thread and post a link to a paper from the University of Minnesota about chest pain due to aortic dissection and what should be done in the ER. This paper describes four heart breaking experiences of failure to diagnose a torn aorta in the ER.

http://www.mmaonline.net/publications/MNMed2005/October/clinical-molina.htm

Arlyss